Method for converting an annuloplasty ring in vivo

ABSTRACT

The invention is a cardiac implant, and associated methods therefore, configured to repair and/or replace a native heart valve, and having a support frame configured to be reshaped into an expanded/changed form in order to receive and/or support an expandable prosthetic heart valve therein. The implant may be configured to have a generally rigid and/or expansion-resistant configuration when initially implanted to replace/repair a native valve (or other prosthetic heart valve), but to assume a generally non-rigid and/or expanded/expandable form when subjected to an outward force such as that provided by a dilation balloon. The implant may be configured to have a generally D-shaped configuration when initially implanted, but to assume a generally circular form when subjected to an outward force such as that provided by a dilation balloon.

CROSS REFERENCE TO RELATED PATENT APPLICATIONS

This application is a divisional of U.S. application Ser. No.15/498,213, filed Apr. 26, 2017, which is a continuation of U.S.application Ser. No. 14/038,357, filed Sep. 26, 2013, now U.S. Pat. No.9,636,219, which is a continuation of U.S. application Ser. No.12/234,559, filed Sep. 19, 2008, now U.S. Pat. No. 9,314,335, the entiredisclosures all of which are incorporated herein by reference for allpurposes. The present application is also related to U.S. patentapplication Ser. No. 12/234,580, filed Sep. 19, 2008, now U.S. Pat. No.8,287,591, the entire disclosure which is incorporated herein byreference for all purposes.

FIELD OF THE INVENTION

The present invention relates to prosthetic cardiac implants for heartvalve replacement and/or repair, and more particularly to a prostheticheart valve and a prosthetic annuloplasty ring configured to receive anexpandable prosthetic heart valve therein.

BACKGROUND OF THE INVENTION

In humans and other vertebrate animals, the heart is a hollow muscularorgan having four pumping chambers separated by four heart valves:aortic, mitral (or bicuspid), tricuspid, and pulmonary. The valves openand close in response to a pressure gradient during each cardiac cycleof relaxation and contraction to control the flow of blood to aparticular region of the heart and/or to blood vessels (pulmonary,aorta, etc.)

These valves are comprised of a dense fibrous ring known as the annulus,and leaflets or cusps attached to the annulus. For some valves, there isalso a complex of chordae tendineae and papillary muscles securing theleaflets. The size of the leaflets or cusps is such that when the heartcontracts the resulting increased blood pressure formed within heartchamber forces the leaflets open to allow flow from the heart chamber.As the pressure in the heart chamber subsides, the pressure in thesubsequent chamber or blood vessel becomes dominant, and presses backagainst the leaflets. As a result, the leaflets or cusps come inapposition to each other, thereby closing the passage.

Heart valve disease is a widespread condition in which one or more ofthe valves of the heart fails to function properly. Diseased heartvalves may be categorized as either stenotic, wherein the valve does notopen sufficiently to allow adequate forward flow of blood through thevalve, and/or incompetent, wherein the valve does not close completely,causing excessive backward flow of blood through the valve when thevalve is closed. Valve disease can be severely debilitating and evenfatal if left untreated. Various surgical techniques may be used toreplace or repair a diseased or damaged valve. In a traditional valvereplacement operation, the damaged leaflets are typically excised andthe annulus sculpted to receive a replacement prosthetic valve. In atraditional valve repair, surgeons insert a ring around the valve tobring the valves into contact with each other, a procedure known as“annuloplasty.”

In many patients who suffer from dysfunction of the mitral and/ortricuspid valves(s) of the heart, surgical repair of the valve (i.e.,“valvuloplasty”) is a desirable alternative to valve replacement.Remodeling of the valve annulus (i.e., “annuloplasty”) is central tomany reconstructive valvuloplasty procedures. In 1968, Dr. AlainCarpentier published studies which demonstrated that such remodeling ofthe valve annulus might be accomplished by implantation of a prostheticring (i.e. “annuloplasty ring”) to stabilize the annulus and to corrector prevent valvular insufficiency that may result from defectdysfunction of the valve annulus. The annuloplasty ring is designed tosupport the functional changes that occur during the cardiac cycle:maintaining coaptation and valve integrity to prevent reverse flow whilepermitting good hemodynamics during forward flow. Annuloplastyprocedures are performed not only to repair damaged or diseased annuli,but also in conjunction with other procedures, such as leaflet repair.

The annuloplasty ring typically comprises an inner substrate of a metalsuch as stainless or titanium, or a flexible material such as siliconerubber or Dacron cordage, covered with a biocompatible fabric or clothto allow the ring to be sutured to the heart tissue. Annuloplasty ringsmay be stiff or flexible, may be split or continuous, and may have avariety of shapes, including circular, D-shaped (includingkidney-shaped), or C-shaped. Examples are seen in U.S. Pat. Nos.4,042,979; 4,290,151; 4,489,446; 4,602,911; 5,041,130; 5,061,277;5,104,407; 5,201,880; 5,258,021; 5,607,471; and 6,187,040, the contentsof each of which is hereby incorporated by reference in its entirety.

For some patients, however, the condition of the native heart valverequires complete replacement using a prosthetic heart valve. Prostheticheart valves have been known for some time, and have been successfullyimplanted using traditional open-chest surgical approaches,minimally-invasive procedures, and so-called percutaneous methods.

A prosthetic heart valve typically comprises a support structure (suchas a ring and/or stent) with a valve assembly deployed therein. Thesupport structure is often rigid, and can be formed of variousbiocompatible materials, including metals, plastics, ceramics, etc. Twoprimary types of “conventional” heart valve replacements or prosthesesare known. One is a mechanical-type heart valve that uses a ball andcage arrangement or a pivoting mechanical closure supported by a basestructure to provide unidirectional blood flow, such as shown in U.S.Pat. No. 6,143,025 to Stobie, et al. and U.S. Pat. No. 6,719,790 toBrendzel, et al., the entire disclosures of which are hereby expresslyincorporated by reference. The other is a tissue-type or “bioprosthetic”valve having flexible leaflets supported by a base structure andprojecting into the flow stream that function much like those of anatural human heart valve and imitate their natural flexing action tocoapt against each other and ensure one-way blood flow.

In tissue-type valves, a whole xenograft valve (e.g., porcine) or aplurality of xenograft leaflets (e.g., bovine pericardium) can providefluid occluding surfaces. Synthetic leaflets have been proposed, andthus the term “flexible leaflet valve” refers to both natural andartificial “tissue-type” valves. In a typical tissue-type valve, two ormore flexible leaflets are mounted within a peripheral support structurethat usually includes posts or commissures extending in the outflowdirection to mimic natural fibrous commissures in the native annulus.Components of the valve are usually assembled with one or morebiocompatible fabric (e.g., Dacron) coverings, and a fabric-coveredsewing ring is provided on the inflow end of the peripheral supportstructure.

In many bioprosthetic-type valves, a metallic or polymeric structureprovides base support for the flexible leaflets, which extend therefrom.One such support is a “support frame,” sometimes called a “wireform” or“stent,” which has a plurality (typically three) of large radius cuspssupporting the cusp region of the flexible leaflets (i.e., either awhole xenograft valve or three separate leaflets). The ends of each pairof adjacent cusps converge somewhat asymptotically to form upstandingcommissures that terminate in tips, each extending in the oppositedirection as the arcuate cusps and having a relatively smaller radius.The support frame typically describes a conical tube with the commissuretips at the small diameter end. This provides an undulating referenceshape to which a fixed edge of each leaflet attaches (via componentssuch as fabric and sutures) much like the natural fibrous skeleton inthe aortic annulus. One example of the construction of a flexibleleaflet valve is seen in U.S. Pat. No. 6,585,766 to Huynh, et al.(issued Jul. 1, 2003), in which the exploded view of FIG. 1 illustratesa fabric-covered wireform 54 and a fabric-covered support stent 56 oneither side of a leaflet subassembly 52. The contents of U.S. Pat. No.6,585,766 are hereby incorporated by reference in their entirety. Otherexamples of valve and related assemblies/systems are found in U.S. Pat.No. 7,137,184, which issued on Nov. 21, 2006, the contents of which arehereby incorporated by reference in their entirety.

Sometimes the need for complete valve replacement may arise after apatient has already had an earlier valve replacement or repair using anannuloplasty ring for the same valve. For example, a native heart valvethat was successfully repaired using an annuloplasty ring may sufferfurther damage years after the annuloplasty ring was implanted.Similarly, a prosthetic heart that was successfully implanted to replacea native valve may itself suffer damage and/or wear and tear many yearsafter initially being implanted.

Implanting a prosthetic heart valve into a patient with apreviously-implanted prosthetic heart valve or annuloplasty ringtypically involves additional steps from a similar procedure in apatient with no previously-implanted heart valve or annuloplasty ring.Implanting the prosthetic heart valve directly within apreviously-implanted prosthetic heart valve is generally impractical, inpart because the new prosthetic heart valve (including the supportstructure and valve assembly) will have to reside within the annulus ofthe previously-implanted heart valve, and traditional prosthetic heartvalves are not configured to easily receive such a valve-within-a-valveimplantation in a manner which provides secure seating for the new valvewhile also having a large enough annulus within the new valve to supportproper blood flow therethrough. Implanting the prosthetic heart valvedirectly within a previously-implanted annuloplasty ring is generallyimpractical, largely because most prosthetic heart valves have agenerally circular shape whereas most annuloplasty rings are generallynon-circular (including “D” and dog-bone shapes). Implanting aprosthetic heart valve in a patient who previously had a prostheticheart valve or annuloplasty ring generally requires thepreviously-implanted heart valve or annuloplasty ring to be removedduring the same procedure in which the new prosthetic heart valve isimplanted. In such cases, a surgeon can use a traditional surgicalapproach to install the prosthetic valve, which can involve the surgeoncutting out the previously-implanted heart valve or annuloplasty ringfrom the heart valve annulus, and then implanting the new prostheticvalve into the heart valve annulus.

Percutaneous and minimally-invasive heart valve replacement has beendeveloped recently, wherein a prosthetic heart valve is advancedpercutaneously (e.g., via the femoral artery or other desiredapproaches) or via other approaches (i.e., minimally-invasive “keyhole”surgery, including approaches via the apex of the heart, etc.) into theheart valve annulus, and then expanded within the heart valve annulus.Various expandable valves are being tested, primarily that use balloon-or self-expanding stents as anchors. For the purpose of inclusivity, theentire field will be denoted herein as the delivery and implantation ofexpandable valves, regardless of whether the delivery method involvespercutaneous, minimally-invasive, or other delivery methods. Thesevalves typically include a scaffold or frame that expands radiallyoutward into direct anchoring contact with the annulus, sometimesassisted with barbs. Examples of percutaneous heart valves and deliverysystems and methods therefore are described in U.S. Pat. No. 5,411,552,issued May 2, 1995; U.S. Pat. No. 5,840,081, issued Nov. 24, 1998; U.S.Pat. No. 6,168,614, issued Jan. 2, 2001; and U.S. Pat. No. 6,582,462,issued Jun. 24, 2003; and also in U.S. patent application Ser. No.11/280,062, filed Nov. 16, 2005; U.S. patent application Ser. No.11/488,510, filed Jul. 18, 2006; and U.S. patent application Ser. No.11/542,087, filed Oct. 2, 2006; the contents of each of which are herebyincorporated by reference in their entirety.

Percutaneous heart valve replacement is often performed without cuttingout the native heart valve, wherein the prosthetic heart valve isexpanded in the native heart valve annulus and the native valve leafletsare pressed against the valve annulus walls by the expanded prostheticheart valve. However, in cases where a previously-implanted prostheticheart valve or annuloplasty ring is present, deploying a prostheticheart valve within the native heart valve annulus may be impractical.The shape and structure of the previously-installed prosthetic heartvalve or annuloplasty ring may interfere with the proper placement,deployment, and functioning of the new prosthetic heart valve.

There is thus a need for a prosthetic heart valve which will properlyreplace a damaged heart valve, but will also enable a replacementexpandable prosthetic heart valve to be deployed therein at a latertime. There is also a need for an annuloplasty prosthesis andimplantation device which will properly reshape/repair a damaged heartvalve, but will also enable a prosthetic heart valve to be deployedtherein at a later time. The current invention meets this need.

SUMMARY OF THE INVENTION

The invention is a prosthetic heart valve and an annuloplasty ringconfigured to receive a prosthetic heart valve, such as acatheter-deployed (transcatheter) prosthetic heart valve, therein. Inone embodiment, the prosthetic heart valve has a support structure whichis generally resistant to expansion when deployed in the patient'snative heart valve annulus to replace the native heart valve (or toreplace another prosthetic heart valve), but is configured to transformto a generally expanded and/or expandable configuration in order toreceive a prosthetic heart valve therein. In another embodiment, theannuloplasty ring has a generally non-circular shape when deployed inthe patient's native heart valve to correct heart valve function, but isconfigured to assume a generally circular configuration when subjectedto a dilation force such as that provided by a dilation balloon used todeploy a prosthetic valve. The annuloplasty ring or prosthetic heartvalve of the invention can be deployed using various surgical techniques(e.g., traditional open-chest, minimally-invasive, percutaneous, etc.)to correct heart valve function, and the expandable prosthetic valve canbe deployed within the same native valve annulus at a much later time.The annuloplasty ring is configured to accept and even improvedeployment of the prosthetic valve within the native valve annulus. Thetransformation from expansion-resistant to expanded/expandable, and/orfrom generally non-circular shape to generally circular configuration,can be achieved by subjecting the heart valve or annuloplasty ringsupport structure to an outward force, such as a dilation force, whichmay be provided by a dilation balloon used to deploy a replacementprosthetic valve.

The prosthetic heart valve structure may be generally rigid prior todilation, and may be configured to become generally non-rigid, and evengenerally elastic, when subjected to an outward force. The elasticitymay assist in holding a percutaneously-introduced prosthetic valvewithin the current prosthetic valve structure.

The prosthetic valve can be initially deployed in the patient's valveannulus using various surgical techniques (e.g., traditional open-chest,minimally-invasive, percutaneous, etc.) to correct heart valve function.If the heart valve function declines further after deployment of theprosthetic valve, a new replacement prosthetic valve can be deployedwithin the previously-deployed prosthetic valve without the need toexcise the previously-deployed prosthetic valve. Deployment of thereplacement prosthetic valve within the previously-deployed prostheticvalve can occur at a much later time from initial deployment of thepreviously-deployed prosthetic valve. The prosthetic valve of thecurrent invention is configured to be deployed in a patient and, at alater time, to accept and even improve deployment of a replacementprosthetic valve within the same valve annulus.

In one embodiment, the structure can include a core comprising a spring,a plastically deformable material (including breakable materials), etc.The core may be formed as a single piece (possibly with one or moreweakened sections configured to fail when subjected to a sufficientforce), or may be formed from several segments connected at seams. Thecore may form an inner lumen through which further attachment devicesmay be passed, such as elastic and/or inelastic cords.

A prosthetic valve according to an embodiment of the invention mayinclude a cover configured to hold the core together after it has beendilated. For example, where a core breaks into multiple pieces duringdilation, the cover can serve to keep the pieces from separating fromthe prosthetic valve. The cover can also serve to hold the core and/orother portions of the support frame in a desired shape, and may haveelastic properties.

In an embodiment of the invention, the prosthetic valve is a stentedbioprosthetic valve configured to expand and contract dynamically withinthe patient's annulus. The dynamic motion of the annulus can enable thevalve opening to expand during periods of peak demand, and reduce theannular restriction to the increased flow. The expansion can alsodecrease leaflet stresses associated with potential higher gradients.The expansion can also permit later placement of an expandableprosthetic valve within the stented bioprosthetic valve.

In an embodiment of the invention, a prosthetic valve has a supportstructure having a generally rigid and/or expansion-resistant portionincluding a core. The prosthetic valve may include plasticallydeformable materials configured to maintain the prosthetic valve supportstructure in the generally rigid and/or expansion-resistant shape fordeployment. The plastically deformable materials may be configured tobreak or otherwise plastically deform and no longer maintain the supportstructure in the generally rigid and/or expansion-resistantconfiguration when subjected to a dilation force. The support structuremay form a continuous loop, and may include elastically deformablematerial configured to provide tension about the continuous loop afterthe support structure has been dilated by a dilation balloon.

A method for repairing a patient's heart function according to anembodiment of the invention can include: providing a prosthetic heartvalve configured to have a generally rigid and/or expansion-resistantsupport structure upon implantation and also configured to assume agenerally non-rigid and/or expanded/expandable configuration upondilation; and implanting the prosthetic heart valve in a heart valveannulus. The method may also include deploying an expandable prostheticheart valve within the previously-deployed heart valve and heart valveannulus. Deploying the expandable prosthetic heart valve within thepreviously-deployed prosthetic valve and heart valve annulus may includedilating the previously-deployed prosthetic valve to cause thepreviously-deployed prosthetic valve to assume a generally non-rigidand/or expanded/expandable shape.

Dilating a previously-deployed prosthetic heart valve may include usinga dilation balloon, such as the type currently used for dilation ofnative heart valves, which can be advanced within thepreviously-deployed prosthetic heart valve and expanded to a desiredpressure and/or diameter. As a general rule, dilation balloons used fordilation of native valves are formed from generally inelastic materialto provide a generally fixed (i.e., pre-set) outer diameter wheninflated. Once such balloons are inflated to their full fixed diameter,they will not appreciably expand further (prior to rupturing) even ifadditional volume/pressure is added therein. Typical pressures forinflating such balloons are between 1 and 6 atmospheres, with pre-setinflated outer diameters of such balloons being on the order of 18 to 33millimeters. The dilation balloon may be expanded to a desired pressure(e.g., 1-6 atmospheres) sufficient to fully inflate the dilation balloonto its desired diameter and to dilate and expand the previously-deployedprosthetic heart valve.

A typical surgically-implanted prosthetic heart valve will withstanddilation pressures of several atmospheres such as provided by mostdilation balloons without expanding and/or becoming elastic. Bycontrast, the prosthetic heart valve of the current invention isconfigured to become expanded and/or generally elastic when subjected tosufficient pressure provided by a dilation balloon. If the dilationballoon is expanded, using sufficient pressure, to an expanded outerdiameter larger than the inner diameter of the prosthetic heart valve ofthe invention, the prosthetic heart valve will expand in diameter and/orbecome elastic.

In one embodiment, the dilation balloon is configured with a pre-setinflated outer diameter which is larger, such as by 10-20% or more, thanthe inner diameter of the previously-deployed prosthetic heart valve. Asan example, if the previously-deployed prosthetic heart valve of theinvention has an inner diameter of 23 mm, a dilation balloon having aninflated diameter of 24-27 mm may be inflated within the prostheticheart valve to cause it to expand and/or become elastic.

Prosthetic heart valves according to various embodiments of theinvention can be configured to be generally rigid prior to dilation, butbecome expanded and/or elastic when subjected to a sufficient dilationpressure. For example, a prosthetic heart valve could be configured towithstand naturally occurring dilation pressures that may occur duringbeating of the heart, but to become expanded and/or elastic whensubjected to a desired pressure (e.g., from a dilation balloon), such asa pressure of 1 atmosphere, 2 atmospheres, 3 atmospheres, 4 atmospheres,5 atmospheres, or 6 atmospheres, depending on the particularapplication.

Note that the dilation balloon inflated diameters and inflatedpressures, as well as the pressures at which the prosthetic heart valveof the invention would become expanded and/or elastic, set forth aboveare by way of example, and that the use of balloons with other pressuresand diameters, and of prosthetic heart valves configured to change shapeand/or expand and/or become elastic when subjected to other pressuresand expanded balloon diameters, are also within the scope of theinvention.

An annuloplasty ring is being developed having a structure that canexpand and/or otherwise change configuration in order to accept apercutaneously-delivered prosthetic heart valve therein. Such anannuloplasty ring is disclosed in U.S. patent application Ser. No.12/234,580, filed Sep. 19, 2008 and entitled “Annuloplasty RingConfigured to Receive a Percutaneous Prosthetic Heart ValveImplantation,” the entire contents of which are incorporated herein byreference. In an embodiment of the invention, the annuloplasty ringdefines a first inner orifice area when deployed in the patient's nativeheart valve to correct heart valve function, but is configured to definea second inner orifice area when subjected to a dilation force such asthat provided by a dilation balloon used to deploy a prosthetic valve,with the second (dilated) orifice area being larger than the first(pre-dilation) orifice area. In an annuloplasty ring which is generallycircular both before and after dilation, the first inner orifice areahas a corresponding first inner diameter, and the second inner orificearea has a corresponding second inner diameter, with the second(post-dilation) inner diameter being larger than the first(pre-dilation) inner diameter.

In one embodiment, the annuloplasty ring has a generally curved portionand a generally straight portion, with the generally curved portionbeing generally rigid and the generally straight portion being generallyflexible. The annuloplasty ring may form a continuous loop or adis-continuous loop, and/or may be generally “D”-shaped (includingkidney shapes) or otherwise generally non-circular. The ring may includeupward and/or downward structures, such as bows, when viewed from theside.

In an embodiment of the invention, an annuloplasty ring is adiscontinuous structure having a generally rigid curved portion and twogenerally straight portions extending therefrom, with the generallystraight portions aligned with each other to form a generally straight(but discontinuous) structure.

An embodiment of the invention includes a first generally rigid section,a second generally rigid section, and a restraint configured to preventmovement of the first generally rigid section with respect to the secondgenerally rigid section, with the restraint further configured to permitmovement of the first generally rigid section with respect to the secondgenerally rigid section when the annuloplasty ring is subjected to adilation force. The restraint may be configured to permit rotationalmovement of the first generally rigid section with respect to the secondgenerally rigid section when the annuloplasty ring is subjected to thedilation force. The restraint may comprise a lock configured to failwhen the annuloplasty ring is subjected to a dilation force. Therestraint may comprise suture, an elastic material or structure such asa spring, a plastically deformable material (including breakablematerials), etc.

An annuloplasty ring according to an embodiment of the invention mayinclude a movable connection between the first generally rigid sectionand the second generally rigid section, wherein the movable connectionis configured to survive application of the dilatation force. Themovable connection may comprise a hinge, a generally flexible materialsuch as tether, etc.

In an embodiment of the invention, an annuloplasty ring has a generallynon-circular shape and has a generally rigid portion defining at leasthalf of the circumference of the generally non-circular shape, and theannuloplasty ring is configured to assume a generally circular shapewhen dilated by a balloon catheter. The annuloplasty ring may includeplastically deformable materials configured to maintain the annuloplastyring in the generally non-circular shape. The plastically deformablematerials may be configured to break or otherwise plastically deform andno longer maintain the annuloplasty ring in the generally non-circularshape when subjected to a dilation force. The annuloplasty ring may forma continuous loop, and may include elastically deformable materialconfigured to provide tension within the continuous loop.

A method for repairing a patient's heart function according to anembodiment of the invention can include: providing an annuloplasty ringhaving a generally non-circular configuration but configured to assume agenerally circular configuration when subjected to a dilatational force;and implanting the annuloplasty ring in a heart valve annulus. Themethod may also include deploying an expandable prosthetic heart valvewithin the annuloplasty ring and heart valve annulus. Deploying theexpandable prosthetic heart valve within the annuloplasty ring and heartvalve annulus may include dilating the annuloplasty ring to cause theannuloplasty ring to assume a generally circular shape.

The generally non-circular configuration of the ring may be a “D”- orkidney-shape, so-called dog-bone shape, etc.

Dilating an annuloplasty ring may include using a dilation balloon, suchas the type currently used for dilation of native heart valves, whichcan be advanced within the annuloplasty ring and expanded to a desiredpressure and/or diameter. As a general rule, dilation balloons used fordilation of native valves are formed from generally inelastic materialto provide a generally fixed (i.e., pre-set) outer diameter wheninflated. Once such balloons are inflated to their full fixed diameter,they will not appreciably expand further (prior to rupturing) even ifadditional volume/pressure is added therein. Typical pressures forinflating such balloons are between 1 and 6 atmospheres, with pre-setinflated outer diameters of such balloons being on the order of 18 to 33millimeters. The dilation balloon may be expanded to a desired pressure(e.g., 1-6 atmospheres) sufficient to fully inflate the dilation balloonto its desired diameter and to dilate and expand the native valve andannuloplasty ring.

A typical rigid annuloplasty ring will withstand dilation pressures ofseveral atmospheres such as provided by most dilation balloons withoutexpanding and/or becoming elastic. By contrast, the annuloplasty ring ofthe current invention is configured to change shape and/or becomeexpanded and/or generally elastic when subjected to sufficient pressureprovided by a dilation balloon. If the dilation balloon is expanded,using sufficient pressure, to an expanded outer diameter larger than theinner diameter of the native valve and annuloplasty ring, theannuloplasty ring will expand in diameter and/or change shape and/orbecome elastic.

In one embodiment, the dilation balloon is configured with a pre-setinflated outer diameter which is larger, such as by 10-20% or more, thanthe inner diameter of the annuloplasty ring. As an example, if theannuloplasty ring of the invention has an inner diameter of 23 mm, adilation balloon having an inflated diameter of 24-27 mm may be inflatedwithin the annuloplasty ring to cause it to expand and/or becomeelastic.

Annuloplasty rings according to various embodiments of the invention canbe configured to be generally rigid prior to dilation, but change shapeand/or become expanded and/or elastic when subjected to a sufficientdilation pressure. For example, an annuloplasty ring could be configuredto withstand naturally occurring dilation pressures that may occurduring beating of the heart, but to become expanded and/or elastic whensubjected to a desired pressure (e.g., from a dilation balloon), such asa pressure of 1 atmosphere, 2 atmospheres, 3 atmospheres, 4 atmospheres,5 atmospheres, or 6 atmospheres, depending on the particularapplication.

Note that the dilation balloon inflated diameters and inflatedpressures, as well as the pressures at which the annuloplasty ring ofthe invention would become expanded and/or elastic, set forth above areby way of example, and that the use of balloons with other pressures anddiameters, and of annuloplasty rings configured to change shape and/orexpand and/or become elastic when subjected to other pressures andexpanded balloon diameters, are also within the scope of the invention.

Other features and advantages of the present invention will becomeapparent from the following detailed description, taken in conjunctionwith the accompanying drawings which illustrate, by way of example, theprinciples of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts a prosthetic heart valve deployed in a heart according toan embodiment of the invention;

FIGS. 2A-2C depict perspective, top, and side views, respectively, of aprosthetic heart valve according to an embodiment of the invention;

FIG. 2D depicts a top view of the prosthetic heart valve of FIGS. 2A-2Cafter the prosthetic heart valve has been dilated;

FIGS. 3A-3C depict side, top (in cross section), and close-up sectionalviews, respectively, of a prosthetic heart valve support structureaccording to an embodiment of the invention;

FIG. 3D depicts a top view of the prosthetic heart valve supportstructure of FIGS. 3A-3C after the prosthetic heart valve supportstructure has been dilated;

FIGS. 4A-4B depict top views of a prosthetic heart valve supportstructure in pre-dilation and post-dilation configurations,respectively, according to an embodiment of the invention;

FIGS. 5A-5B depict top views of a prosthetic heart valve supportstructure in pre-dilation and post-dilation configurations,respectively, according to an embodiment of the invention;

FIGS. 6A-6C depict top, side, and close-up sectional views,respectively, of a prosthetic heart valve support structure according toan embodiment of the invention;

FIG. 6D depicts a top view of the prosthetic heart valve supportstructure of FIGS. 6A-6C after the prosthetic heart valve supportstructure has been dilated;

FIGS. 6E and 6F depict close-up top views of a portion, in expanded andunexpanded configurations, respectively, of a prosthetic heart valvesupport structure according to an embodiment of the invention;

FIGS. 7A and 7B depict top views of unexpanded and expandedconfigurations, respectively, of a prosthetic heart valve supportstructure according to an embodiment of the invention;

FIG. 8A depicts an expandable prosthetic heart valve deployment catheterconfigured for annuloplasty ring dilation and expandable prostheticheart valve deployment according to an embodiment of the invention;

FIG. 8B depicts the expandable prosthetic heart valve deploymentcatheter of FIG. 8A positioned within a previously-deployed prostheticheart valve in a heart valve annulus of a patient according to anembodiment of the invention;

FIG. 8C depicts the expandable prosthetic heart valve deploymentcatheter of FIG. 8A dilating the previously-deployed prosthetic heartvalve and deploying an expandable prosthetic heart valve therewithinaccording to an embodiment of the invention;

FIG. 8D depicts the expandable prosthetic heart valve deploymentcatheter of FIG. 8A being withdrawn from the patient according to anembodiment of the invention;

FIG. 9A depicts an expandable prosthetic heart valve deployment catheterconfigured for dilation of a previously-deployed prosthetic heart valveand for deployment of an expandable prosthetic heart valve according toan embodiment of the invention;

FIG. 9B depicts the expandable prosthetic heart valve deploymentcatheter of FIG. 9A with the dilation balloon positioned within thepreviously-deployed prosthetic heart valve in the heart valve annulusaccording to an embodiment of the invention;

FIG. 9C depicts the expandable prosthetic heart valve deploymentcatheter of FIG. 9A dilating the previously-deployed prosthetic heartvalve according to an embodiment of the invention;

FIG. 9D depicts the expandable prosthetic heart valve deploymentcatheter of FIG. 9A with the dilation balloon deflated after dilation ofthe previously-deployed prosthetic heart valve according to anembodiment of the invention;

FIG. 10 depicts an annuloplasty ring deployed in a heart according to anembodiment of the invention;

FIG. 11A depicts a top view of an annuloplasty ring according to anembodiment of the invention;

FIG. 11B depicts a top view of the annuloplasty ring of FIG. 11A afterthe annuloplasty ring has been dilated;

FIG. 12A depicts a top view of an annuloplasty ring according to afurther embodiment of the invention;

FIG. 12B depicts a top view of the annuloplasty ring of FIG. 12A afterthe annuloplasty ring has been dilated;

FIGS. 13A and 13B depict perspective and top views, respectively, of anannuloplasty ring according to a further embodiment of the invention;

FIGS. 13C and 13D depict perspective and top views, respectively, of theannuloplasty ring of FIGS. 13A and 13B after the annuloplasty ring hasbeen dilated;

FIG. 14A depicts a perspective view of an annuloplasty ring according toa further embodiment of the invention;

FIG. 14B depicts a perspective view of the annuloplasty ring of FIG. 14Aafter the annuloplasty ring has been dilated;

FIG. 15A depicts a prosthetic heart valve deployment catheter configuredfor annuloplasty ring dilation and prosthetic heart valve deploymentaccording to an embodiment of the invention;

FIG. 15B depicts the prosthetic heart valve deployment catheter of FIG.15A positioned within a heart valve annulus of a patient according to anembodiment of the invention;

FIG. 15C depicts the prosthetic heart valve deployment catheter of FIG.15A dilating the annuloplasty ring and deploying the prosthetic heartvalve according to an embodiment of the invention;

FIG. 15D depicts the prosthetic heart valve deployment catheter of FIG.15A being withdrawn from the patient according to an embodiment of theinvention;

FIG. 16A depicts a prosthetic heart valve deployment catheter configuredfor annuloplasty ring dilation and prosthetic heart valve deploymentaccording to an embodiment of the invention;

FIG. 16B depicts the prosthetic heart valve deployment catheter of FIG.16A with the proximal dilation balloon positioned within the heart valveannulus according to an embodiment of the invention;

FIG. 16C depicts the prosthetic heart valve deployment catheter of FIG.16A dilating the annuloplasty ring according to an embodiment of theinvention;

FIG. 16D depicts the prosthetic heart valve deployment catheter of FIG.16A with the proximal dilation balloon deflated according to anembodiment of the invention;

FIGS. 17A-17C depict side, top (in cross-section), and close-upsectional views, respectively, of an annuloplasty ring according to anembodiment of the invention;

FIG. 17D depicts a top view, in cross-section, of the annuloplasty ringof FIGS. 17A-17C after the annuloplasty ring has been dilated;

FIGS. 18A and 18B depict top views, in pre-dilation and post-dilationconfigurations, of an annuloplasty ring according to an embodiment ofthe invention;

FIGS. 19A-19C depict top, side, and cross-sectional views, respectively,of an annuloplasty ring according to an embodiment of the invention;

FIG. 19D depicts a top view, in expanded configuration, of theannuloplasty ring of FIGS. 19A-19C; and

FIGS. 19E and 19F depict close-up top views, in undilated and dilatedconfigurations, respectively, of an annuloplasty ring according to anembodiment of the invention.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

With reference to FIG. 1, a prosthetic heart valve 10 according to theinvention is depicted in a heart 12. The heart 12 has four chambers,known as the right atrium 14, right ventricle 16, left atrium 18, andleft ventricle 20. The general anatomy of the heart 12, which isdepicted as viewed from the front of a patient, will be described forbackground purposes. The heart 12 has a muscular outer wall 22, with aninteratrial septum 24 dividing the right atrium 14 and left atrium 18,and a muscular interventricular septum 26 dividing the right ventricle16 and left ventricle 20. At the bottom end of the heart 12 is the apex28.

Blood flows through the superior vena cava 30 and the inferior vena cava32 into the right atrium 14 of the heart 12. The tricuspid valve 34,which has three leaflets 36, controls blood flow between the rightatrium 14 and the right ventricle 16. The tricuspid valve 34 is closedwhen blood is pumped out from the right ventricle 16 through thepulmonary valve 38 to the pulmonary artery 40 which branches intoarteries leading to the lungs (not shown). Thereafter, the tricuspidvalve 34 is opened to refill the right ventricle 16 with blood from theright atrium 14. Lower portions and free edges 42 of leaflets 36 of thetricuspid valve 34 are connected via tricuspid chordae tendineae 44 topapillary muscles 46 in the right ventricle 16 for controlling themovements of the tricuspid valve 34.

After exiting the lungs, the newly-oxygenated blood flows through thepulmonary veins 48 and enters the left atrium 18 of the heart 12. Themitral valve in a normal heart controls blood flow between the leftatrium 18 and the left ventricle 20. Note that in the current figure,the native mitral valve has been replaced with the prosthetic heartvalve 10, which is accordingly a prosthetic mitral valve 50. Theprosthetic mitral valve 50 is closed during ventricular systole whenblood is ejected from the left ventricle 20 into the aorta 52.Thereafter, the prosthetic mitral valve 50 is opened to refill the leftventricle 20 with blood from the left atrium 18. Blood from the leftventricle 20 is pumped by power created from the musculature of theheart wall 22 and the muscular interventricular septum 26 through theaortic valve 62 into the aorta 52 which branches into arteries leadingto all parts of the body.

In the particular embodiment depicted, the prosthetic heart valve 10 isdeployed to replace a native mitral valve, and more particularly issecured (via, e.g., sutures) adjacent and around the mitral valveannulus 64. Depending on the particular application, including themethod by which the prosthetic heart valve 10 was implanted, theparticular native valve (mitral, tricuspid, etc.) and/or some or all ofits associated structures may be entirely or partially removed prior toor during implantation of the prosthetic heart valve 10, or the nativevalve and/or some or all associated structures may simply be left inplace with the prosthetic heart valve 10 installed over the nativevalve. For example, a native mitral valve typically has two leaflets(anterior leaflet and posterior leaflet), lower portions and free edgesof which are connected via mitral chordae tendineae to papillary muscles60 in the left ventricle 20 for controlling the movements of the mitralvalve. Not all of these structures (i.e., mitral valve leaflets, chordaetendineae) are depicted in FIG. 1 because, in the particular embodiment,the native mitral valve and many associated structures (chordae, etc.)have been removed prior to or during implantation of the prostheticheart valve 10. However, in many prosthetic valve implantations,surgeons choose to preserve many of the chordae tendineae, etc., evenwhen excising the native valve.

Although FIG. 1 depicts a prosthetic mitral valve, note that theinvention can be applied to prosthetic valves (and systems and methodstherefore) configured to replacement of any heart valves, includingaortic, mitral, tricuspid, and pulmonary valves.

FIGS. 2A-2C depict a prosthetic heart valve 70 according to anembodiment of the invention, where the prosthetic heart valve 70comprises a support frame 72 and valve structure 74. In the particularembodiment depicted, the valve structure 74 comprises three heart valveleaflets 76. The prosthetic heart valve 70 has an inner diameter 78 a ofa valve orifice 80 through which blood may flow in one direction, butthe valve leaflets 76 will prevent blood flow in the opposite direction.The support frame 74 is generally rigid and/or expansion-resistant inorder to maintain the particular shape (which in this embodiment isgenerally round) and diameter 78 a of the valve orifice 80 and also tomaintain the respective valve leaflets 76 in proper alignment in orderfor the valve structure 74 to properly close and open. The particularsupport frame 74 also includes commissure supports 75. In the particularembodiment depicted in FIGS. 2A-2C, the support frame 74 defines agenerally rigid and/or expansion-resistant ring 82 which encircles thevalve 70 and defines a generally round valve orifice 80, but othershapes are also within the scope of the invention, depending on theparticular application (including issues such as the particular nativevalve to be replaced, etc.) The particular prosthetic heart valve 70includes visualization markers 73 (such as radiopaque markers, etc.),which in the current embodiment are on the support frame 74 andcorrespond to the ring 82 and also to the commissure supports 75 (andhence to the commissures), which can aid in proper placement of asubsequently-deployed expandable prosthetic heart valve within the valveorifice 80 of the prosthetic heart valve 70.

When the prosthetic heart valve 70 of FIGS. 2A-2C is subjected to adilation force (such as that from a dilation balloon, which may providepressures of 1 to 5 atmospheres), the prosthetic heart valve will beexpanded somewhat. The support frame 74 will transition from thegenerally rigid and/or expansion-resistant configuration of FIGS. 2A-2Cto a generally non-rigid and expanded configuration depicted in FIG. 2D.Note that the ring 82, which was generally rigid and/orexpansion-resistant, is now generally non-rigid and is expanded, and thevalve orifice 80 has accordingly been enlarged to a larger innerdiameter 78 b. The larger inner diameter 78 b is configured to receivean expandable prosthetic heart valve therein. The overall result is thatthe “post-dilation” prosthetic heart valve 70 of FIG. 2D has a generallylarger inner diameter circular opening 78 b. The actual inner diameterswill depend on the particular application, including aspects of theparticular patient's heart (e.g., native valve and/or annulus diameter,etc.). As an example, the pre-dilation inner diameter 78 a for a mitralvalve may be between 25-33 mm, or for an aortic valve 18-28 mm. Thepost-dilation inner diameter 78 b will be larger, and more specificallylarge enough to accommodate the outer diameter of an expandableprosthetic valve therein.

In some procedures where an expandable prosthetic heart valve is used toreplace/repair a previously-deployed prosthetic heart valve, it may bedesirable for the expandable prosthetic heart valve to have a deployed(expanded) inner diameter (and corresponding expandable prosthetic heartvalve orifice area) approximately equal to the pre-dilation innerdiameter 78 a (and corresponding pre-dilation prosthetic valve orificearea) of the previously-deployed prosthetic heart valve 70. Suchconsistency between inner diameters/orifice areas can be useful inmaintaining proper blood flow, so that the expandable prosthetic heartvalve will provide the same blood flow as was provided by thepreviously-deployed prosthetic heart valve. Note that the term “valveorifice area” refers to the area of the valve orifice when the valveportion is in the fully open configuration (e.g., with the valveleaflets in their fully open configuration so that the effective orificearea is at its maximum size).

For example, Edwards Lifesciences has Sapien™ expandable prostheticheart valves having outer diameters of 23 and 26 mm, respectively, whichhave corresponding inner diameters of about 20 and 23 mm, respectively.Accordingly, the post-dilation inner diameter 78 b of the(previously-deployed) prosthetic heart valve may be on the order of 23and 26 mm (respectively) to accommodate such expandable prosthetic heartvalves. This corresponds to a post-dilation inner diameter 78 b beingabout 10 to 20% larger than the pre-dilation inner diameter 78 a.Accordingly, embodiments of the invention include a prosthetic heartvalve having a post-dilation inner diameter 78 b that is about 10, 15,or 20%, or between 5-25%, 10-20%, or 13-17% of the pre-dilation innerdiameter 78 a.

Note that the invention is not limited to the above differences betweenpre- and post-dilation inner diameters. For example, there may beapplications where much smaller and/or much larger post-dilation innerdiameters may be required. In some cases an expandable prosthetic heartvalve will have an outer diameter only slightly larger than its innerdiameter, so that less expansion of the previously-deployed prostheticheart valve inner diameter is required in order to accommodate theexpandable prosthetic heart valve. In other cases an expandableprosthetic heart valve may have an outer diameter that is much largerthan its inner diameter, so that a greater expansion of thepreviously-deployed prosthetic heart valve inner diameter is necessaryto accommodate the expandable prosthetic heart valve. There may also beapplications where it may be desirable to deploy an expandableprosthetic heart valve having a smaller or larger inner diameter thanwas provided by the (previously-deployed and pre-dilation) prostheticheart valve.

Note that, depending on the particular embodiment, a prosthetic heartvalve 70 according to the invention may return to its pre-dilation innerdiameter 78 a after being subject to dilation such as from a balloondilation catheter. However, the balloon dilation will have rendered the“post-dilation” prosthetic heart valve 70 into a generally non-rigidand/or expansion-friendly configuration, so that the “post-dilation”prosthetic heart valve 70 will be forced with relative ease into alarger diameter (such as 78 b) when an expandable (e.g.,balloon-expandable, self-expanding, etc.) prosthetic heart valve isdeployed within the valve orifice 80 of the prosthetic heart valve 70.

FIGS. 3A-3C depicts a prosthetic heart valve 90 having a valve structure92 and support frame 94 according to a further embodiment of theinvention, with the prosthetic heart valve 90 having a valve orifice 96having an inner diameter 98 a. The support frame 94 has a generallyrigid and expansion-resistant core 100 formed from a single core element102 which is bent or otherwise formed into a generally circular shapewith opposing ends 104 a, 104 b meeting at a seam 106 so as to form thecomplete circle. The seam 106 may include adhesive, solder, welds, etc.in order to secure the two ends 104 a, 104 b together. The prostheticheart valve 90 includes a covering 108 around the support core 96. Thecovering 108 may be a cloth-like material, and may be a sewing ringconfigured to be sewn to the native heart valve annulus duringdeployment of the prosthetic heart valve 90. The covering 108 isgenerally flexible, and may be generally elastic. The covering 108 (or aportion thereof) may also be generally compressible, especially in theportion facing inward toward the valve orifice 96, which can assist inseating an expandable valve therein. A compressible material may beapplied onto or within the covering 108 in a position to provide acompressible region on the surface facing inward toward the valveorifice 96.

When the prosthetic heart valve 90 is subject to a dilation force suchas that from a dilation balloon catheter, the support frame 94 willbecome non-rigid and expanded. More particularly, the seam 106 of thecore 100 will rupture, so that the opposing ends 104 a, 104 b will beseparated by an opening 110, and the core 100 will assume a generallyC-shaped configuration as depicted in FIG. 3D. The covering 108 willstretch or otherwise expand circumferentially to accommodate theenlarged/expanded core 100, and the prosthetic heart valve 90 will havean enlarged inner diameter 98 b for the valve orifice 96. Depending onthe particular embodiment, including the particular construction of thecore 100 and/or covering, the (post-dilation) prosthetic heart valve 90may provide an inward (i.e., compressive) force toward the valve orifice96. For example, the core 100 may be formed of a generally resilientspring-like material and/or memory material, and may be biased somewhattoward its non-dilated configuration (i.e., with the opposing ends 104a, 104 b touching each other as in FIGS. 3A-3C). The covering 108 mayalso (or alternatively) be elastic and, after dilation of the prostheticheart valve 90, may provide an inward pull on the core 100 so as to biasthe opposing ends 104 a, 104 b toward each other. This inward pressurecan help to seat an expandable heart valve that may be deployed withinthe prosthetic heart valve 90. In an embodiment where compressiblematerial is provided (e.g., as part of the covering 108) facing inwardtoward the valve orifice 96, then the compressible material can provideadditional assistance in seating an expandable heart valve within theprosthetic heart valve 90.

FIG. 4A depicts a further embodiment of a support frame 120 for use witha prosthetic heart valve according to the invention. The support frame120 is generally circular and defines an inner diameter 122 a, and has agenerally rigid core 124 formed from a single core element 126 which isbent or otherwise formed into a generally circular shape with opposingends 128 a, 128 b which meet and connect at an overlapping section 130having a length 132 a. The overlapping section 130 may include adhesive,solder, welds, mechanical connections, etc. in order to secure theoverlapping ends 128 a, 128 b together. In the particular embodimentdepicted, the overlapping section 130 has a ratchet-like assembly formedfrom interacting portions 134 a, 134 b at or adjacent the opposing ends128 a, 128 b. The support frame 120 may include a covering (not shown)around the core 124.

FIG. 4B depicts the support frame 120 of FIG. 4A after it has beensubjected to a dilation force. The support frame 120 has been expandedto a larger inner diameter 122 b, with the core 124 enlarged so that theoverlapping section 130 is smaller, having a new shorter length 132 b.The dilation force caused the interacting portions 134 a, 134 b totemporarily release their connection to permit the relative movement ofthe overlapping ends 128 a, 128 b, but with the dilation force removedthe interacting portions 134 a, 134 b once again form a connection, sothat the support frame 120 is again generally rigid. Note that,depending on the particular application, a support frame could be formedsimilar to that of FIGS. 4A-4B but with the interacting portionsconfigured so that no fixed connection is formed between the overlappingends after dilation, so that the support frame will be generallynon-rigid after the dilation force has been applied. In such anembodiment, the support frame may be configured to provide (afterdilation) an inward (compressive) force upon any expandable prostheticvalve that may be deployed within the valve orifice of the original (andnow dilated) prosthetic valve. This inward compressive force may help toseat and otherwise hold the expandable prosthetic valve in its desiredposition within the native valve annulus and also within the now-dilated(prior) prosthetic valve.

FIGS. 5A-5B depict a further embodiment of a support frame 120 for usewith a prosthetic heart valve according to the invention. The supportframe 120 is similar to that depicted in FIG. 4A, except the overlappingsection 130 includes a sliding mechanical connection 136 having a slot137 secured to one opposing end 128 a, the second opposing end 128 bhaving been passed through the slot 137 to form the overlapping section130, and also including a spring 138 extending from the slot 137 to thesecond opposing end 128 b. The spring 138 permits expansion and/orcontraction of the support frame 120, with the spring 138 generallybiasing the support frame 120 toward a smaller diameter, such as thesmaller inner diameter 122 a of FIG. 5A, but also permitting the supportframe 120 to be expanded, when subject to an outside force such as adilation balloon and/or expandable prosthetic valve, to a largerdiameter such as the inner diameter 122 b of FIG. 5B. Note that thespring 138 can also permit the support frame 120 (and associated valveannulus) to move with physiological annular dynamic motion, e.g., tomake smaller expansions and/or contractions in response to normal valvefunction/heart movement as the patient's heart beats and pumps bloodthrough the valve. The support frame 120 may include a covering (notshown) around the core 124. The support frame 120 may be formed ofvarious materials, including elgiloy. The spring 138 can be configuredto provide a specific force in opposing expansion of the support frame120, and may be configured so that the force provided is insufficient tooppose the dilation force from a dilation balloon and/or expandablestent which might be expanded within the support frame 120. The spring138 could be formed from traditional coil springs, compressiblematerials, pleated sewing rings, accordion sewing rings, and otherconfigurations configured to provide a spring-like force.

In another embodiment of the invention, a prosthetic heart valveincludes a support frame having a rigid and/or expansion-resistant coreconfigured to separate into a plurality of pieces when subjected to adilation force. Such a rigid and/or expansion-resistant core could beformed as a single piece, which might include one or more weak pointsthat are subject to separation when subjected to a dilation force. Inone embodiment a rigid and/or expansion-resistant core could be formedfrom a plurality of segments positioned in edge-to-edge fashion andconfigured to separate when subjected to a dilation force. FIGS. 6A-6Cdepict one such embodiment of a support frame 140 for use with aprosthetic heart valve according to the invention. The support frame 140is generally circular (although other shapes are within the scope of theinvention) and defines an orifice 141 having an inner diameter 142 a,and has a generally rigid and/or expansion-resistant core 144 formedfrom multiple core segments 146 which are arranged in edge-to-edgefashion to form the generally circular shape of the core 144. Eachsegment 146 has an inner lumen 148, with the segments 146 when assembledinto the core 144 forming a continuous core lumen 150.

Adjacent segments 146 join at seams 152, which may include adhesive,solder, welds, etc. in order to secure and/or seal the seam 152 betweenthe adjacent segments 146. The support frame 140 has a pre-dilation cord154 and a post-dilation cord 156 passing through the core lumen 150. Thepre-dilation cord 154 may be a generally inelastic cord which issufficiently tight to hold adjacent segments together and to preventunwanted dilation of the support frame 140. A covering (not shown) mayalso be included to cover the core 144. The covering may be formed ofcloth, and may be elastic.

Both the seams 152 and pre-dilation cord 154 are configured to fail orstretch when subjected to a dilation force, such as that provided by adilation balloon, whereupon the support frame 140 will assume theexpanded configuration depicted in FIG. 6D, with an enlarged innerdiameter 142 b. For example, the pre-dilation cord 154 may be aninelastic cord configured to fail when subject to a selected force, suchas 1, 2, 3, 4, or more atmospheres, which are within the range of forcesprovided by many dilation balloons used in percutaneously-deployed heartvalve procedures. In one embodiment, the seams 152 are merely sealed,with the sealant providing little if any securement against separationof adjacent segments 146. In such an embodiment, the pre-dilation cord154 may serve as the sole device to hold the core segments 146 togetherin the rigid and/or expansion-resistant (pre-dilation) configuration.Once the pre-dilation cord 154 fails or stretches due to the dilationpressure, essentially all of the seams 152 will separate so thatadjacent segments 146 separate with spaces 158 separating the adjacentsegments 146. The remaining portions of the pre-dilation cord 154 remainwithin the support frame 140 after dilation.

The post-dilation cord 156 remains intact after dilation and may serveto hold the support frame 140 together post-dilation. The post-dilationcord 156 could be elastic, and/or could be inelastic and have a largerdiameter, and possibly a higher failure strength, than the pre-dilationcord 154. If the post-dilation cord 156 is elastic, it may provide aninward compressive force into the central orifice 141. If thepost-dilation cord 156 is generally inelastic, it will remain intactafter dilation either because its strength was too great to be rupturedby the dilation balloon or because it had a diameter that was largerthan that of the inflated dilation balloon.

In a variation of the embodiment of FIGS. 6A-6D, the pre-dilation cord154 could be left out of the support frame 140, and the seams 152themselves could have adhesive or other connections that serve to holdthe segments 146 together prior to dilation. In a further variation, thepre-dilation cord 154 could be left out of the support frame, with apost-dilation cord 156 configured to be elastic and with sufficientstrength/elasticity to provide an inward compressive force into thecentral orifice with sufficient strength to hold the segments 146together prior to dilation, but with the inward compressive force weakenough to permit the support frame 140 to be dilated and to permit anexpandable prosthetic heart valve to be deployed therein. Accordingly,the post-dilation cord 156 would serve as both pre-dilation cord andpost-dilation cord.

Visualization references (such as the visualization markers 73 fromFIGS. 2A-2D) may be included on or in various portions of the device.For example, visualization references may be placed on, in, or adjacentthe support frame 140, core 144, segments 146, pre-dilation cord 154,and/or post-dilation cord 156, etc. in the device of FIGS. 6A-6D. Suchvisualization references can help a user to properly position a dilationballoon and/or subsequently-deployed expandable prosthetic heart valvewithin the previously-deployed prosthetic heart valve having the supportframe 140. For example, visualization markers positioned at thegenerally rigid support frame 140 (or more specifically at the segments146 and/or the pre-dilation cord 154 and/or post-dilation cord 156)could be used to guide delivery and expansion of a dilation balloon, andalso to confirm that the support frame 140 has been dilated. Thevisualization markers could also be used to guide delivery and expansionof the expandable prosthetic heart valve within the support frame 140,and to confirm proper deployment of the expandable prosthetic heartvalve.

The support frame 140 may have segments 146 having ends 146 a, 146 bwhich interlock and/or otherwise interact in order to hold the segments146 together and/or in alignment. As depicted in the close-up view ofFIG. 6E, adjacent segments 146 may include interconnecting ends 146 a,146 b, with one end 146 a having a member 147 configured to be receivedwithin the lumen 148 or other opening in an end 146 b of an adjacentsegment 146. The interconnecting ends 146 a, 146 b keep the adjacentsegments 146 in a desired alignment so that the segment ends 146 a, 146b cannot slide sideways with respect to the member 147 and lumen 148,but does permit the segments 146 to be pulled apart, as depicted in FIG.6F, in order to permit expansion of the support frame 140 (as wasdepicted in FIG. 6D). The pulling apart of the segments 146 may beopposed by various structures set forth herein which oppose and/orrestrict dilation of a support frame, such as one or more elastic and/orinelastic cords 155 configured to oppose and/or restrict dilation of thesupport frame as was depicted in FIGS. 6A-6D.

FIGS. 7A-7B depict a further embodiment of the invention, with aprosthetic heart valve 160 having a valve structure 162 formed fromthree (3) leaflets 164 spaced around the valve orifice 166. The supportframe 168 includes a core 170 formed from three (3) segments 172. At thebase/perimeter of the valve structure 162, the edges 165 of each leaflet164 coincide with the edges of each respective segment 172 as well asthe seams 174 (and the commissure supports, if present). Adjacentsegments 172 are connected to each other at the seams 174, such as withadhesive(s), weld(s), etc., in order to form the rigid and/orexpansion-resistant (pre-dilation) support frame 168. Adjacent segments172 are also connected via individual inelastic cords 176 and elasticcords 178 extending between the adjacent segments 172. As depicted inFIG. 7A, the (pre-dilation) prosthetic valve 160 has a valve orifice 166having an inner diameter 180 a. A cloth cover (not shown) or similarcovering will also typically be included to cover the support frame 168and its associated elements (e.g., inelastic cords 176 and elastic cords178).

When the prosthetic heart valve 160 of FIG. 7A is subjected to adilation force, the seams 174 between the segments 172 will fail and thesupport frame 168 will separate into the three segments 172, as depictedin FIG. 7B. Note that in this particular embodiment the inelastic cords176 do not serve to hold adjacent segments against each other, butinstead permit adjacent segments to separate when subjected to adilation force. The inelastic cords 176 prevent excessive separationbetween any adjacent segments 172 as the dilation balloon (or otherdilation force) is applied, with the result being that the segments 172will all be spaced generally equally apart from each other once the fulldilation force is applied. After the dilation force is removed, theelastic cords 178 will serve to pull the adjacent segments toward eachother and to provide a generally inward (compressive) pressure to thevalve orifice 166 but while also maintaining the post-dilation innerdiameter 180 b (FIG. 7B) at a larger size than the pre-dilation diameter180 a (FIG. 7A). Because the leaflets 164 were positioned with theirbase edges coinciding with the seams 174 between segments 172, theleaflets 164 can remain generally intact after dilation and still permitthe segments 172 to separate to form the enlarged inner diameter 180 b.Note, however, that deploying a new expandable prosthetic valve withinthe prosthetic heart valve 160 will generally involve deploying anexpandable heart valve support stent that will crush the leaflets 164 ofthe current prosthetic heart valve 160 against the support frame 168,walls of the native valve annulus, and/or lumen.

If the prosthetic heart valve 160 includes commissure supports (notshown) on the support frame 168, the commissure supports can bepositioned on or adjacent the seams 174 between segments 172, and thecommissure supports can also be configured to split lengthwise when theprosthetic heart valve 160 is dilated so that one-half of eachcommissure support will remain with the adjacent segment 172 on eitherside of said commissure support. In such an embodiment, the edges of thevalve leaflets 164 can be secured (e.g., during assembly of theprosthetic heart valve 160) to the respective half of each commissuresupport, so that when the prosthetic heart valve 160 is dilated adjacentleaflets 164 can separate from adjacent leaflets 164, but each leaflet164 will still remain secured via its edges to its respective commissuresupport halves.

There are many variations of the above-cited embodiments, includingvarious combinations of the various embodiments. For example, thepre-dilation cord 154 and/or post-dilation cord 156 of FIGS. 6A-6D couldbe used with the core 100 of FIGS. 3A-3D in order to provide inwardcompressive force after the core 100 was dilated. The post-dilation cord156 of FIGS. 6A-6D could be replaced by a cover 108 such as thatdepicted in FIGS. 3A-3D, with the cover 108 serving to hold thepost-dilation core assembly (including any segments and/or piecesthereof) together and also (if formed form elastic material) providingan inward compressive force to the valve orifice.

FIG. 8A depicts an expandable prosthetic heart valve deployment catheter220 configured for (prior) prosthetic heart valve dilation and(replacement) expandable prosthetic heart valve deployment. Thedeployment catheter 220 has an elongated main body 222, a proximal end224, and a distal end 226. The proximal end 224 includes a handle 228.The distal end 226 includes a dilation balloon 230 upon which anexpandable prosthetic valve 232 is mounted. In the particular embodimentdepicted, the expandable prosthetic valve 232 includes a stent 234. Thedistal end 226 may also include one or more radiopaque markers 233 orsimilar visibility markers to improve visibility of the device withinthe patient when using fluoroscopy or other viewing technologies.

FIGS. 8B-8D depict deployment of an expandable prosthetic heart valve232 within a heart valve annulus 236 where a prosthetic heart valve 10has previously been deployed. The previously-deployed prosthetic heartvalve 10 may have been deployed using any methods, including methodscurrently known in the art such as traditional (open chest) surgery,minimally-invasive (e.g., keyhole) surgery, and percutaneous surgery.Depending on the particular application, the previously-deployedprosthetic heart valve 10 can be deployed in the patient years prior to,days prior to, hours prior to, or immediately prior to deployment of theexpandable prosthetic heart valve 232 as depicted in FIGS. 8B-8D.

FIG. 8B depicts the expandable prosthetic heart valve deploymentcatheter 220 of FIG. 8A with the distal end 226 advanced so that thedilation balloon 230 and expandable prosthetic heart valve 232 arepositioned within the previously-deployed prosthetic heart valve 10 inthe patient's heart 240. The previously-deployed prosthetic heart valve10 is seen in cross-section to show the generally rigid and/orexpansion-resistant support frame 238.

In the particular embodiment depicted in FIG. 8B, the deploymentcatheter 220 has been advanced over a guide wire 242, which was advancedinto the patient's heart 240 and previously-deployed prosthetic heartvalve 10 prior to advancement of the deployment catheter 220 into thepatient. Note that the use of a guide wire 242 is optional. Other guidedevices could also be used, in addition to or in lieu of a guide wire.For example, a guide catheter could be used, wherein a guide catheter isadvanced to a desired position within a patient, and the deploymentcatheter is then advanced into the patient inside of the guide catheteruntil the distal end of the deployment catheter extends from a distalopening in the guide catheter. A deployment catheter could also be usedwithout any sort of guide wire or guide catheter, so that the deploymentcatheter is guided by itself into the desired treatment location.

As depicted in FIG. 8C, once the dilation balloon 230 and expandableprosthetic heart valve 232 are properly positioned within the heartvalve annulus 234 and previously-deployed prosthetic heart valve 10, thedilation balloon 230 is expanded. The expanding dilation balloon 230forces the stent 234 to expand outwardly, and crushes the leaflets 244of the previously-deployed prosthetic heart valve 10 against the heartvalve annulus 236. The force from the expanding dilation balloon 230also dilates the previously-deployed prosthetic heart valve 10 and heartvalve annulus 236, forcing the support frame 238 of thepreviously-deployed prosthetic heart valve 10 to expand and/or becomenon-rigid.

In FIG. 8D, the dilation balloon 230 is deflated or otherwise reduced indiameter, with the new expandable prosthetic valve 232 deployed in theheart valve annulus 236 and previously-deployed prosthetic heart valve10, and also held in place by the stent 234. The outward pressure fromthe expanded stent 232, along with the inward pressure from the heartvalve annulus 236 and from any elastic portions (such as core, cords,and/or or covers) of the previously-deployed prosthetic heart valve 10or from the now-crushed previously-deployed prosthetic heart valveleaflets 244, combine to firmly seat the new expandable prosthetic valve232 in the desired position in the heart valve annulus 236 andpreviously-deployed prosthetic heart valve 10. The deployment catheter220 with the dilation balloon 230 can then be withdrawn from the heart240, leaving the new expandable prosthetic heart valve 232 in itsdeployed position within the patient and the previously-deployedprosthetic heart valve 10.

In a further embodiment of the invention, the previously-deployedprosthetic heart valve 10 is dilated in a separate step from deploymentof the expandable prosthetic heart valve 232. FIG. 9A depicts anexpandable prosthetic heart valve deployment catheter 220 configured forpreviously-deployed prosthetic heart valve dilation and expandableprosthetic heart valve deployment using two separate balloons, and morespecifically a distal balloon 230 a and a proximal balloon 230 b. Thedistal balloon 230 a is configured to deploy the new expandableprosthetic valve 232, which is positioned on the distal balloon 230 a,whereas the proximal balloon 230 b is configured for dilation of thepreviously-deployed prosthetic heart valve 10.

FIGS. 9B-9D depict dilation of the previously-deployed prosthetic heartvalve 10 and valve annulus 236 using the proximal balloon 230 b. In FIG.9B, the deployment catheter 220 has been advanced into the heart 230with the distal balloon 230 a (with expandable prosthetic valve 232thereon) advanced past the previously-deployed prosthetic heart valve10, and the proximal balloon 230 b positioned within thepreviously-deployed prosthetic heart valve 10 and valve annulus 236.

The proximal balloon 230 b is inflated or otherwise expanded, asdepicted in FIG. 9C, thereby dilating the previously-deployed prostheticheart valve 10 and valve annulus 236. The support frame 238 of thepreviously-deployed prosthetic heart valve 10 is expanded and/or assumesa generally non-rigid configuration, similarly to the changes previouslydiscussed with respect to the dilation discussed in FIG. 8C above.

After dilation of the previously-deployed prosthetic heart valve 10, theproximal balloon 230 b is deflated or otherwise reduced in diameter, asdepicted in FIG. 9D. The deployment catheter 220 may then be withdrawnfrom the patient until the proximal balloon 230 b is proximal of thepreviously-deployed prosthetic heart valve 10 and the distal balloon 230a is positioned within the previously-deployed prosthetic heart valve10. The distal balloon 230 a will be positioned within thepreviously-deployed prosthetic heart valve 10 in a similar fashion tothat depicted for balloon 230 in FIG. 8B. The distal balloon 230 a willthen be expanded to deploy the expandable prosthetic valve 232 inessentially the same manner as was discussed and depicted in FIGS.8B-8D. The distal balloon 230 a will serve to deploy the new expandableprosthetic valve 232, and may also serve to further dilate thepreviously-deployed prosthetic heart valve 10 and/or native valveannulus 236.

Note that the expandable prosthetic valve may be self-expanding, inwhich case the deployment catheter may not have a dilation balloon asdepicted in FIGS. 8A-8D and 9A-9D. Moreover, such a self-expandingprosthetic heart valve could be deployed with or without prior dilationof the previously-deployed prosthetic heart valve. For example, aself-expanding prosthetic heart valve may provide sufficient outwardradial force to dilate the previously-deployed prosthetic heart valveand/or to hold a now-dilated previously-deployed prosthetic heart valvein an expanded configuration in order to provide sufficient room for theself-expanding prosthetic heart valve in its expanded configuration.

With reference to FIG. 10, an annuloplasty ring device 1010 according tothe invention is depicted in a heart 12. In the particular embodimentdepicted, the annuloplasty ring 1010 is deployed in the mitral valve1050, and more particularly is secured (via, e.g., sutures) adjacent andaround the mitral valve annulus 64. The mitral valve 1050 has twoleaflets (anterior leaflet 1054 a and posterior leaflet 1054 p), lowerportions and free edges 1056 of which are connected via mitral chordaetendineae 1058 to papillary muscles 60 in the left ventricle 20 forcontrolling the movements of the mitral valve 1050. The annuloplastyring 1010 provides a desired shape to the mitral valve annulus 64,thereby providing proper alignment and closure of the mitral valveleaflets 1054 a, 1054 p.

FIG. 11A depicts a top view of an annuloplasty ring 1070 according to anembodiment of the invention, where the annuloplasty ring 1010 isgenerally “D”-shaped and has a generally rigid portion 1072 andgenerally flexible portion 1074. In the particular embodiment depictedin FIG. 11A, the generally rigid portion 1072 is generally curved, butthe generally flexible portion 1074 is generally straight.

When the annuloplasty ring 1070 of FIG. 11A is subjected to a dilationforce (such as that from a dilation balloon), the annuloplasty ring 1070will transition from the generally “D”-shaped configuration of FIG. 11Ato the generally circular shape of FIG. 11B. While the generally rigidportion 1072 has remained generally unchanged in shaped (i.e., is stillgenerally curved), the generally flexible portion 1074 has transitionedfrom the generally straight configuration of FIG. 11A to the generallycurved configuration of FIG. 11B. The overall result is that the“post-dilation” annuloplasty ring 1070 of FIG. 11B has a generallycircular opening 1076 when viewed from the top.

FIG. 12A depicts a top view of an annuloplasty ring 1080 according to afurther embodiment of the invention, where the annuloplasty ring 1080 isgenerally “D”-shaped and has a generally rigid portion 1082 and agenerally flexible portion 1084 which has two separate generallyflexible portions 1084 a, 1084 b. The annuloplasty ring 1080 of FIG. 12Ais accordingly discontinuous in structure (as opposed to the continuousstructure of FIGS. 11A-11B). In the particular embodiment depicted inFIG. 12A, the generally rigid portion 1082 is generally curved, but eachof the generally flexible portions 1084 a, 1084 b are generally straightand are also generally aligned so that the generally flexible portion1084 is generally straight.

When the annuloplasty ring 1080 of FIG. 12A is subjected to a dilationforce (such as that from a dilation balloon), the annuloplasty ring 1080will transition from the generally “D”-shaped configuration of FIG. 12Ato the generally circular (but still discontinuous) shape of FIG. 12B.While the generally rigid portion 1082 has remained generally unchangedin shaped (i.e., is still generally curved), the generally flexibleportions 1084 a, 1084 b have transitioned from the generally straightconfigurations of FIG. 12A to the generally curved configurations ofFIG. 12B. The overall result is that the “post-dilation” annuloplastyring 1080 of FIG. 12B is generally circular but discontinuous whenviewed from the top, providing a generally circular opening 1086.

FIGS. 13A-13D depict a further embodiment of the invention, where anannuloplasty ring 1090 has a first generally rigid portion 1092 andsecond generally rigid portion 1094. As depicted in FIGS. 13A-13B, theannuloplasty ring 1090 in its pre-dilation configuration is generallyD-shaped, with the second generally rigid portion 1094 being shorterthan the first generally rigid portion 1092. The second generally rigidportion 1092 defines a curve 1096 which is directed inward with respectto the ring opening 1098.

The first generally rigid portion 1092 and second generally rigidportion 1094 of the annuloplasty ring 1090 are held together via amovable connection, which in the particular embodiment is formed by twohinges 1100 secured to either end of the first generally rigid portion1092 and second generally rigid portion 1094. The hinges 1100 permit thesecond generally rigid portion 1094 to rotate relative to the firstgenerally rigid portion 1092 when an outward force, such as thatprovided from an expanded dilation balloon, is applied to theannuloplasty ring 1090. When the second generally rigid portion 1094 isrotated relative to the first generally rigid portion 1092 responsive tosuch an outward force, the annuloplasty ring 1090 will transform fromthe generally D-shaped configuration of FIGS. 13A-13B to the generallycircular configuration of FIGS. 13C-13D.

In order to prevent unwanted rotation of the second generally rigidportion 1094 with respect to the first generally rigid portion 1092, alock or other restraint 1102 is provided. The restraint 1102 preventsrotation of the second generally rigid portion 1094 with respect to thefirst generally rigid portion 1092 prior to application of a dilatationforce. However, the restraint 1102 is configured to fail or open orotherwise release upon application of a significant dilation force (suchas that provided by a dilation balloon) to permit movement (which in theparticular embodiment depicted is in the form of rotation) of the secondgenerally rigid section 1094 with respect to the first generally rigidsection 1092 when the annuloplasty ring 1090 is subjected to thedilation force.

In the particular embodiment of FIG. 13A, the restraint 1102 compriseslines of suture 1104 tied between the first generally rigid portion 1092and second generally rigid portion 1094. Other types of restraints arealso within the scope of the invention, including elastically deformablematerials and/or structures such as springs, and plastically deformablematerials (including breakable materials) such as suture, metals,plastics, etc.

In a further embodiment of the invention depicted in FIGS. 14A-14B, theannuloplasty ring 1110 has a restraint 1116 that is a plasticallydeformable material (e.g., a bendable metal) that prevents relativemovement/rotation of the two generally rigid sections 1112, 1114 priorto application of the dilation force, but upon application of thedilation force permits relative rotational or other movement while stillproviding a connection between the sections 1112, 1114. The restraint1116 may be a wire-like connection that can be bent to a desired shapein order to permit the two generally rigid sections 1112, 1114 to rotaterelative to each other.

FIG. 15A depicts a prosthetic heart valve deployment catheter 1120configured for annuloplasty ring dilation and prosthetic heart valvedeployment. The deployment catheter 1120 has an elongated main body1122, a proximal end 1124, and a distal end 1126. The proximal end 1124includes a handle 1128. The distal end 1126 includes a dilation balloon1130 upon which an expandable prosthetic valve 1132 is mounted. In theparticular embodiment depicted, the prosthetic valve 1132 includes astent 1134. The distal end 1126 may also include one or more radiopaquemarkers 1133 or similar visibility markers to improve visibility of thedevice within the patient when using fluoroscopy or other viewingtechnologies.

FIGS. 15B-15D depict deployment of a prosthetic heart valve 1132 withina heart valve annulus 1136 for a heart valve 1138 where an annuloplastyring 1010 has previously been deployed. The annuloplasty ring 1010 mayhave been deployed using any methods, including methods currently knownin the art such as traditional (open chest) surgery, minimally-invasive(e.g., keyhole) surgery, and percutaneous surgery. The annuloplasty ring1010 encircles the heart valve 1138. Depending on the particularapplication, the annuloplasty ring 1010 can be deployed in the patientyears prior to, days prior to, hours prior to, or immediately prior todeployment of the prosthetic heart valve 1132 as depicted in FIGS.15B-15D.

FIG. 15B depicts the prosthetic heart valve deployment catheter 1120 ofFIG. 15A with the distal end 1126 advanced so that the dilation balloon1130 and expandable prosthetic heart valve 1132 are positioned withinthe heart valve 1138 in the patient's heart 1140. The annuloplasty ring1010 is seen in cross-section, with a cross section of the ring firstportion 1010 a at the right side of the valve annulus 1136, and a crosssection of the ring second portion 1010 b at the left side of the valveannulus 1136. Note that the ring second portion 1010 b is depicted asextending somewhat more inward with respect to the valve annulus 1134,which might be the case where the ring 1010 is generally D-shaped andotherwise similar to that depicted in FIGS. 11A-11B and 13A-13C, withthe ring first portion 1010 a corresponds to ring portions 1072 (FIG.11A), 1092 (FIG. 13A), and the ring second portion 1010 b corresponds toring portions 1074 (FIG. 11A), 1094 (FIG. 13A), respectively.

In the particular embodiment depicted in FIG. 15B, the deploymentcatheter 1120 has been advanced over a guide wire 1142, which wasadvanced into the patient's heart 1140 and heart valve 1138 prior toadvancement of the deployment catheter 1120 into the patient. Note thatthe use of a guide wire 1142 is optional. Other guide devices could alsobe used, in addition to or in lieu of a guide wire. For example, a guidecatheter could be used, wherein a guide catheter is advanced to adesired position within a patient, and the deployment catheter is thenadvanced into the patient inside of the guide catheter until the distalend of the deployment catheter extends from a distal opening in theguide catheter. A deployment catheter could also be used without anysort of guide wire or guide catheter, so that the deployment catheter isguided by itself into the desired treatment location.

As depicted in FIG. 15C, once the dilation balloon 1130 and prostheticheart valve 1132 are properly positioned within the heart valve annulus1134, the dilation balloon 1130 is expanded. The expanding dilationballoon 1130 forces the stent 1134 to expand outwardly, and crushes thenative valve leaflets 1144 against the heart valve annulus 1136. Theforce from the expanding dilation balloon 1130 dilates the heart valveannulus 1136, and also forces the annuloplasty ring 1010 to expandand/or assume a more circular shape, which in the particular embodimentdepicted involves displacing the ring second portion 1010 b outward to amuch greater extent than the outward movement of the ring first portion1010 a.

In FIG. 15D, the dilation balloon 1130 is deflated or otherwise reducedin diameter, with the prosthetic valve 1132 deployed in the heart valveannulus 1136 and held in place by the stent 1134. The outward pressurefrom the expanded stent 1132, along with the inward pressure from theheart valve annulus 1136, from the now-crushed native valves 1144,and/or from the now-dilated annuloplasty ring 1010, combine to firmlyseat the prosthetic valve 1132 in the desired position in the heartvalve annulus 1136. The deployment catheter 1120 with the dilationballoon 1130 can then be withdrawn from the heart 1140, leaving theprosthetic heart valve 1132 in its deployed position in the patient.

In a further embodiment of the invention, the native heart valve 1138 isdilated in a separate step from deployment of the prosthetic heart valve1132. FIG. 16A depicts a prosthetic heart valve deployment catheter 1120configured for annuloplasty ring dilation and prosthetic heart valvedeployment using two separate balloons, and more specifically a distalballoon 1130 a and a proximal balloon 1130 b. The distal balloon 1130 ais configured to deploy the prosthetic valve 1132, which is positionedon the distal balloon 1130 a, whereas the proximal balloon 1130 b isconfigured for dilation.

FIGS. 16B-16D depict dilation of the native valve 1138, valve annulus1136, and annuloplasty ring 1010 using the proximal balloon 1130 b. InFIG. 16B, the deployment catheter 1120 has been advanced into the heart1130 with the distal balloon 1130 a (with prosthetic valve 1132 thereon)advanced past the native heart valve 1138, and the proximal balloon 1130b positioned within the native heart valve 1138 and valve annulus 1136.

The proximal balloon 1130 b is inflated or otherwise expanded, asdepicted in FIG. 16C, thereby dilating the native valve 1138, valveannulus 1136, and annuloplasty ring 1010. The annuloplasty ring 1010 isexpanded and/or assumes a more circular form, similarly to the changespreviously discussed with respect to the dilation discussed in FIG. 15Cabove.

After dilation of the native valve 1138, the proximal balloon 1130 b isdeflated or otherwise reduced in diameter, as depicted in FIG. 16D. Thedeployment catheter 1120 may then be withdrawn from the patient untilthe proximal balloon 1130 b is proximal of the valve annulus 1138 andthe distal balloon 1130 a is positioned within the valve annulus 1138.The distal balloon 1130 a will be positioned within the valve annulus138 in a similar fashion to that depicted for balloon 1130 in FIG. 15B.The distal balloon 1130 a will then be expanded to deploy the prostheticvalve 1132 in essentially the same manner as was discussed and depictedin FIGS. 15B-15D. The distal balloon 1130 a will serve to deploy theprosthetic valve 1132, and may also serve to further dilate the nativevalve native valve 1138, valve annulus 1136, and annuloplasty ring 1010.

Note that the expandable prosthetic valve may be self-expanding, inwhich case the deployment catheter may not have a dilation balloon asdepicted in FIGS. 15A-15D and 16A-16D. Moreover, such a self-expandingprosthetic heart valve could be deployed with or without prior dilationof the annuloplasty ring. For example, a self-expanding prosthetic heartvalve may provide sufficient outward radial force to dilate theannuloplasty ring and/or to hold the now-dilated annuloplasty ring in anexpanded configuration in order to provide sufficient room for theself-expanding prosthetic heart valve in it expanded configuration.

FIGS. 17A-17C depict an annuloplasty ring prosthetic heart valve 1150having a support frame 1152 according to a further embodiment of theinvention, with the annuloplasty ring 1150 having an orifice 1154 havingan inner diameter 1156 a. The support frame 1152 has a generally rigidand expansion-resistant core 1158 formed from a single core element 1160which is bent or otherwise formed into a desired shape (which in theparticular embodiment is generally circular) with opposing ends 1162 a,1162 b meeting at a seam 1164 so as to form the complete loop around theannuloplasty ring 1150. The seam 1164 may include adhesive, solder,welds, etc. in order to secure the two ends 1162 a, 1162 b together. Theannuloplasty ring 1150 includes a covering 1166 around the support core1158. The covering 1166 may be a cloth-like material, and may be asewing ring configured to be sewn to the native heart valve annulusduring deployment of the annuloplasty ring 1150. The covering 1166 isgenerally flexible, and may be generally elastic. The covering 1166 (ora portion thereof) may also be generally compressible, especially in theportion facing inward toward the orifice 1154, which can assist inseating an expandable valve therein. A compressible material may beapplied onto or within the covering 1166 in a position to provide acompressible region on the surface facing inward toward the orifice1154.

When the annuloplasty ring 1150 is subject to a dilation force such asthat from a dilation balloon catheter, the support frame 1152 willbecome non-rigid and expanded. More particularly, the seam 1164 of thecore 1158 will rupture, so that the opposing ends 1162 a, 1162 b will beseparated by an opening 1168, and the core 1158 will assume a generallyC-shaped configuration as depicted in FIG. 17D. The covering 1166 willstretch or otherwise expand circumferentially to accommodate theenlarged/expanded core 1158, and the annuloplasty ring 1150 will have anenlarged inner diameter 1156 b for the orifice 1154. Depending on theparticular embodiment, including the particular construction of the core1158 and/or covering 1166, the (post-dilation) annuloplasty ring 1150may provide an inward (i.e., compressive) force toward the orifice 1154.For example, the core 1158 may be formed of a generally resilientspring-like material and/or memory material, and may be biased somewhattoward its non-dilated configuration (i.e., with the opposing ends 1162a, 1162 b touching each other as in FIGS. 17A-17C). The covering 1166may also (or alternatively) be elastic and, after dilation of theannuloplasty ring 1150, may provide an inward pull on the core 1160 soas to bias the opposing ends 1162 a, 1162 b toward each other. Thisinward pressure can help to seat an expandable heart valve that may bedeployed within the annuloplasty ring 1150 and native heart valve. In anembodiment where compressible material is provided (e.g., as part of thecovering 1166) facing inward toward the orifice 1154, then thecompressible material can provide additional assistance in seating anexpandable heart valve within the annuloplasty ring 1150.

In some procedures where an expandable prosthetic heart valve is used toreplace a native valve that has a previously-deployed annuloplasty ring,it may be desirable for the expandable prosthetic heart valve to have adeployed (expanded) orifice having a cross-sectional area approximatelyequal to the orifice cross-sectional area of the native valve. Suchconsistency between orifice areas can be useful in maintaining properblood flow, so that the expandable prosthetic heart valve will providethe same blood flow as was provided by the native heart valve. Forexample, Edwards Lifesciences has Sapien™ expandable prosthetic heartvalves having outer diameters of 23 and 26 mm, respectively, which havecorresponding inner diameters of about 20 and 23 mm, respectively, whichcorrespond to orifice areas of about 315 and 415 square mm,respectively. Accordingly, the post-dilation orifice area of the nativevalve orifice with annuloplasty ring may be on the order of 315 and 415square mm (respectively) to accommodate such expandable prosthetic heartvalves. In that several embodiments of annuloplasty rings herein aregenerally circular in shape after dilation, the post-dilation nativevalve orifice will generally be circular and require diameters of about20 and 23 mm to accommodate the above-discussed Sapien™ expandableprosthetic heart valves. The dilated native valve orifice will generallybe smaller than the dilated annuloplasty ring orifice area due toportions of the native valve (such as leaflets, etc) that can projectinward of the annuloplasty ring.

In order to accommodate an expandable prosthetic heart valve, anannuloplasty ring according to some embodiments of the current inventionwill have a dilated inner orifice area that is larger by about 10%, 15%,25%, 30%, or more than the pre-dilation inner orifice area. Where anannuloplasty ring is generally circular both prior to a after dilation,the annuloplasty ring post-dilation inner diameter may be larger byabout 15%, 20%, 25%, 30%, 35%, or more than the pre-dilation innerdiameter.

Note that the invention is not limited to the above differences betweenpre- and post-dilation inner diameters and/or orifice areas of theannuloplasty ring. For example, there may be applications where muchsmaller and/or much larger post-dilation inner diameters may berequired. In some cases an expandable prosthetic heart valve will havean outer diameter only slightly larger than its inner diameter, so thatless expansion of the native valve orifice (and accordingly of theannuloplasty ring) is required in order to accommodate the expandableprosthetic heart valve. In other cases an expandable prosthetic heartvalve may have an outer diameter that is much larger than its innerdiameter, so that a greater expansion of the native heart valve andassociated annuloplasty ring is necessary to accommodate the expandableprosthetic heart valve. There may also be applications where it may bedesirable to deploy an expandable prosthetic heart valve having asmaller or larger inner diameter than was provided by the native valve.

FIGS. 18A-18B depict a further embodiment of the invention, wherein asupport frame 1170 configured for use with an annuloplasty ring (such asthe ring 1150 in FIGS. 17A-17D) according to the invention. Theparticular support frame 1170 is generally circular (although othershapes are within the scope of the invention) and defines an innerdiameter 1172 a, and has a generally rigid core 1174 formed from asingle core element 1176 which is bent or otherwise formed into agenerally circular shape with opposing ends 1178 a, 1178 b which meetand connect at an overlapping section 1180 having a length 1182 a. Theoverlapping section 1180 may include adhesive, solder, welds, mechanicalconnections, ratchet-like assemblies, interacting portions, etc. inorder to secure the overlapping ends 1178 a, 1178 b together. In theparticular embodiment of FIGS. 18A-18B, the overlapping section 1180includes a sliding mechanical connection 1184 having a slot 1186 securedto one opposing end 1178 a, the second opposing end 1178 b having beenpassed through the slot 1186 to form the overlapping section 1180, andalso including a spring 1188 extending from the slot 1186 to the secondopposing end 1178 b. The spring 1188 permits expansion and/orcontraction of the support frame 1170, with the spring 1188 generallybiasing the support frame 1170 toward a smaller diameter, such as thesmaller inner diameter 1172 a of FIG. 18A. The mechanical connection1184 also permits the support frame 1170 to be expanded when subject toan outside force such as a dilation balloon and/or expandable prostheticvalve. When the support frame is expanded 1170, the overlapping section1180 shortens to a smaller length 1182 b, and the inner diameterincreases to a larger inner diameter 1172 b as depicted in FIG. 18B.Note that the spring 1188 can also permit the support frame 1170 (andassociated annuloplasty ring) to move with physiological annular dynamicmotion, e.g., to make smaller expansions and/or contractions in responseto normal valve function/heart movement as the patient's heart beats andpumps blood through the valve. The support frame 1170 may include acovering (not shown) around the core 1174, with the covering providing asurface through which suture can be passed to secure the annuloplastyring to the native valve annulus. The support frame 1170 may be formedof various materials, including Elgiloy. The spring 1188 can beconfigured to provide a specific force in opposing expansion of thesupport frame 1170, and may be configured so that the force provided isinsufficient to oppose the dilation force from a dilation balloon and/orexpandable stent which might be expanded within the support frame 1170.The spring 1188 could be formed from traditional coil springs,compressible materials, pleated sewing rings, accordion sewing rings,and other configurations configured to provide a spring-like force.

Although a spring-like configuration that survives dilation is depictedin FIGS. 18A-18B, other embodiments are also within the scope of theinvention. For example, a support structure may have overlappingportions having interacting portions that hold the overlapping portionstogether, but that will temporarily release their connection to permitthe relative movement of the overlapping ends when subject to a dilationforce, and then for the interacting portions to re-establish theirconnection once the dilation force is removed so that the support framewill again be generally rigid. Such an embodiment is generally rigidprior to dilation, becomes elastically expandable during dilation, andthen becomes substantially rigid again after dilation. In a furtherembodiment, a support frame could be formed but with the interactingportions configured so that no fixed connection is formed between theoverlapping ends after dilation, so that the support frame will begenerally non-rigid after the dilation force has been applied. In suchan embodiment, the support frame may be configured to provide (afterdilation) an inward (compressive) force upon any expandable prostheticvalve that may be deployed within the annuloplasty ring. This inwardcompressive force may help to seat and otherwise hold the expandableprosthetic valve in its desired position within the native valve annulusand also within the now-dilated annuloplasty ring.

In another embodiment of the invention, an annuloplasty ring includes asupport frame having a rigid and/or expansion-resistant core configuredto separate into a plurality of pieces when subjected to a dilationforce. Such a rigid and/or expansion-resistant core could be formed as asingle piece, which might include one or more weak points that aresubject to separation when subjected to a dilation force. In oneembodiment a rigid and/or expansion-resistant core could be formed froma plurality of segments positioned in edge-to-edge fashion andconfigured to separate when subjected to a dilation force. FIGS. 19A-19Cdepict one such embodiment of a support frame 1190 for use with aprosthetic heart valve according to the invention. The support frame1190 is generally circular (although other shapes are within the scopeof the invention) and defines an orifice 1191 having an inner diameter1192 a, and has a generally rigid and/or expansion-resistant core 1194formed from multiple core segments 1196 which are arranged inedge-to-edge fashion to form the generally circular shape of the core1194. Each segment 1196 has an inner lumen 1198, with the segments 1196when assembled into the core 1194 forming a continuous core lumen 1200.

Adjacent segments 1196 join at seams 1202, which may include adhesive,solder, welds, etc. in order to secure and/or seal the seam 1202 betweenthe adjacent segments 1196. The support frame 1190 has a pre-dilationcord 1204 and a post-dilation cord 1206 passing through the core lumen1200. The pre-dilation cord 1204 may be a generally inelastic cord whichis sufficiently tight to hold adjacent segments together and to preventunwanted dilation of the support frame 1190. A covering (not shown) mayalso be included to cover the core 1194. The covering may be formed ofcloth, and may be elastic.

Both the seams 1202 and pre-dilation cord 1204 are configured to fail orstretch when subjected to a dilation force, such as that provided by adilation balloon, whereupon the support frame 1190 will assume theexpanded configuration depicted in FIG. 19D, with an enlarged innerdiameter 1192 b. For example, the pre-dilation cord 1204 may be aninelastic cord configured to fail when subject to a selected force, suchas 1, 2, 3, 4, or more atmospheres, which are within the range of forcesprovided by many dilation balloons used in percutaneously-deployed heartvalve procedures. In one embodiment, the seams 1202 are merely sealed,with the sealant providing little if any securement against separationof adjacent segments 1196. In such an embodiment, the pre-dilation cord1204 may serve as the sole device to hold the core segments 1196together in the rigid and/or expansion-resistant (pre-dilation)configuration. Once the pre-dilation cord 1204 fails or stretches due tothe dilation pressure, essentially all of the seams 1202 will separateso that adjacent segments 1196 separate with spaces 1208 separating theadjacent segments 1196. The remaining portions of the pre-dilation cord1204 remain within the support frame 1190 after dilation.

The post-dilation cord 1206 remains intact after dilation and can serveto hold the support frame 1190 together post-dilation. The post-dilationcord 1206 could be elastic, and/or could be inelastic and have a largerdiameter, and possibly a higher failure strength, than the pre-dilationcord 1204. If the post-dilation cord 1206 is elastic, it may provide aninward compressive force into the central orifice 1191. If thepost-dilation cord 1206 is generally inelastic, it will remain intactafter dilation either because its strength was too great to be rupturedby the dilation balloon or because it had a diameter that was largerthan that of the inflated dilation balloon.

In a variation of the embodiment of FIGS. 19A-19D, the pre-dilation cord1204 could be left out of the support frame 1190, and the seams 1202themselves could have adhesive or other connections that serve to holdthe segments 1196 together prior to dilation. In a further variation,the pre-dilation cord 1194 could be left out of the support frame, witha post-dilation cord 1206 configured to be elastic and with sufficientstrength/elasticity to provide an inward compressive force into thecentral orifice with sufficient strength to hold the segments 1196together prior to dilation, but with the inward compressive force weakenough to permit the support frame 1190 to be dilated and to permit anexpandable prosthetic heart valve to be deployed therein. Accordingly,the post-dilation cord 1206 would serve as both pre-dilation cord andpost-dilation cord.

Visualization references may be included on or in various portions ofthe device according to various embodiments of the invention. Forexample, visualization references may be placed on, in, or adjacent thesupport frame 1190, core 1194, segments 1196, pre-dilation cord 1204,and/or post-dilation cord 1206, etc. in the device of FIGS. 19A-19D.Such visualization references can help a user to properly position adilation balloon and/or expandable prosthetic heart valve within theannuloplasty ring having the support frame 1190. For example,visualization markers positioned at the generally rigid support frame1190 (or more specifically at the segments 1196 and/or the pre-dilationcord 1204 and/or post-dilation cord 1206) could be used to guidedelivery and expansion of a dilation balloon, and also to confirm thatthe support frame 1190 and annuloplasty ring have been dilated. Thevisualization markers could also be used to guide delivery and expansionof the expandable prosthetic heart valve within the annuloplasty ringand support frame 1190, and to confirm proper deployment of theexpandable prosthetic heart valve.

The support frame 1190 may have segments 1196 having ends 1196 a, 1196 bwhich interlock and/or otherwise interact in order to hold the segments1196 together and/or in alignment. As depicted in the close-up view ofFIG. 19E, adjacent segments 1196 may include interconnecting ends 1196a, 1196 b, with one end 1196 a having a member 1197 configured to bereceived within the lumen 1198 or other opening in an end 1196 b of anadjacent segment 1196. The interconnecting ends 1196 a, 1196 b keep theadjacent segments 1196 in a desired alignment so that the segment ends1196 a, 1196 b cannot slide sideways with respect to the member 1197 andlumen 1148, so that the general shape of the support frame 1190 ismaintained. The interconnecting ends 1196 a, 1196 b do permit theadjacent segments 1196 to be pulled apart, as depicted in FIG. 19F, inorder to permit expansion of the support frame 1190 (as was depicted inFIG. 19D). The pulling apart of the segments 1196 may be opposed byvarious structures set forth herein which oppose and/or restrictdilation of a support frame, such as one or more elastic and/orinelastic cords 1205 configured to oppose and/or restrict dilation ofthe support frame 1190 as was depicted in FIGS. 19A-19D.

Further embodiments of the invention may include an annuloplasty ringhaving a support frame including a core formed from segments connectedend-to-end to form seams, with adjacent segments further connected viaone or more individual inelastic and/or inelastic cords and elasticcords which extend only between adjacent segments. When the annuloplastyring is subjected to a dilation force, the seams between the segmentswill fail and the support frame will separate into the individualsegments 1172. In one particular embodiment the inelastic cords do notserve to hold adjacent segments against each other, but instead permitadjacent segments to separate when subjected to a dilation force. Theinelastic cords prevent excessive separation between any adjacentsegments as the dilation balloon (or other dilation force) is applied,with the result being that the segments will all be spaced generallyequally apart from each other once the full dilation force is applied.After the dilation force is removed, the elastic cords will serve topull the adjacent segments toward each other and to provide a generallyinward (compressive) pressure to the valve orifice while also permittingthe post-dilation inner diameter of the annuloplasty ring to be a largersize than the pre-dilation diameter.

There are many variations of the above-cited embodiments, includingvarious combinations of the various embodiments. For example, thepre-dilation cord 1204 and/or post-dilation cord 1206 of FIGS. 19A-19Dcould be used with the core 1150 of FIGS. 17A-17D in order to provideinward compressive force after the core 1150 was dilated. Thepost-dilation cord 1206 of FIGS. 19A-19D could be replaced by a cover1158 such as that depicted in FIGS. 17A-17D, with the cover 1158 servingto hold the post-dilation core assembly (including any segments and/orpieces thereof) together and also (if formed form elastic material)providing an inward compressive force to the orifice.

Note that, depending on the particular embodiment, an annuloplasty ringaccording to the invention may return to its pre-dilation inner diameterand/or shape after being subject to dilation such as from a ballooncatheter. However, in such an embodiment, the balloon dilation will haverendered the “post-dilation” annuloplasty ring into a generallynon-rigid and/or expansion-friendly configuration, such that a“post-dilation” annuloplasty ring will be forced with relative ease intoa larger diameter and/or different shape when an expandable (e.g.,balloon-expandable, self-expanding, etc.) prosthetic heart valve isdeployed within the valve orifice of the native valve and annuloplastyring.

While the invention has been described with reference to particularembodiments, it will be understood that various changes and additionalvariations may be made and equivalents may be substituted for elementsthereof without departing from the scope of the invention or theinventive concept thereof. In addition, many modifications may be madeto adapt a particular situation or device to the teachings of theinvention without departing from the essential scope thereof. Therefore,it is intended that the invention not be limited to the particularembodiments disclosed herein, but that the invention will include allembodiments falling within the scope of the appended claims.

What is claimed is:
 1. A method of converting an annuloplasty ring invivo, comprising: accessing an annuloplasty ring pre-implanted at anative annulus, the annuloplasty ring having an annuloplasty supportframe defining a circumferential shape surrounding a ring opening asseen when view from above, wherein the annuloplasty support frame isconfigured to transition from a first configuration to a secondconfiguration only upon being subjected to a radially expansive force invivo of at least 1 atm, and wherein in the first configuration the ringopening is non-circular and in the second configuration the ring openingis more circular; inflating a dilatation balloon in vivo to apply aradially expansive force of at least 1 atm within the ring opening tocause the annuloplasty support frame to transition from the firstconfiguration to the second configuration; deploying an expandableprosthetic heart valve within the annuloplasty ring in the secondconfiguration; and expanding the prosthetic heart valve within theannuloplasty ring.
 2. The method of claim 1, wherein the annuloplastysupport frame has a rigid portion and a flexible portion, and the rigidportion remains unchanged in shape while the flexible portion changesshape between the first configuration and the second configuration. 3.The method of claim 2, wherein the rigid portion is curved, and theflexible portion is generally straight in the first configuration andchanges shape to be curved in the second configuration.
 4. The method ofclaim 1, wherein the annuloplasty support frame has a first rigidportion and second rigid portion shorter than and connected to the firstrigid portion via a movable connection between juxtaposed ends of therigid portions, and wherein the second rigid portion moves relative tothe first rigid portion and relative to the native annulus between thefirst configuration and the second configuration.
 5. The method of claim4, wherein the movable connection is formed by two hinges securedbetween juxtaposed ends of the rigid portions configured to permit thesecond rigid portion to rotate relative to the first rigid portion. 6.The method of claim 4, wherein the movable connection is formed by aplastically deformable wire-like connection between juxtaposed ends ofthe rigid portions.
 7. The method of claim 4, wherein the second rigidportion defines a curve which is directed inward with respect to thering opening in the first configuration.
 8. The method of claim 4,further including a restraint to prevent unwanted movement of the secondrigid portion with respect to the first rigid portion prior toapplication of a radially expansive force, and the restraint isconfigured to release upon application of the radially expansive force.9. The method of claim 8, wherein the restraint comprises a line ofsuture tied between the first rigid portion and the second rigidportion.
 10. The method of claim 1, wherein the annuloplasty supportframe defines a closed shape.
 11. The method of claim 1, wherein theannuloplasty support frame defines an open, discontinuous shape.
 12. Amethod of converting an annuloplasty ring in vivo, comprising: accessingan annuloplasty ring pre-implanted at a native annulus, the annuloplastyring having an annuloplasty support frame defining a circumferentialshape surrounding a ring opening as seen when view from above, whereinthe annuloplasty support frame is configured to transition from a firstconfiguration to a second configuration only upon being subjected to aradially expansive force, and wherein in the first configuration thering opening is non-circular and in the second configuration the ringopening is more circular, wherein the annuloplasty support frame furtherhas a restraint to prevent unwanted conversion from the firstconfiguration to the second configuration prior to application of aradially expansive force; inflating a dilatation balloon in vivo toapply a radially expansive force within the ring opening to overcome therestraint and cause the annuloplasty support frame to transition fromthe first configuration to the second configuration; deploying anexpandable prosthetic heart valve within the annuloplasty ring in thesecond configuration; and expanding the prosthetic heart valve withinthe annuloplasty ring.
 13. The method of claim 12, wherein theannuloplasty support frame has a first rigid portion and second rigidportion shorter than and connected to the first rigid portion via amovable connection between juxtaposed ends of the rigid portions, andwherein the second rigid portion moves relative to the first rigidportion and relative to the native annulus between the firstconfiguration and the second configuration.
 14. The method of claim 13,wherein the movable connection is formed by two hinges secured betweenjuxtaposed ends of the rigid portions configured to permit the secondrigid portion to rotate relative to the first rigid portion.
 15. Themethod of claim 13, wherein the movable connection is formed by aplastically deformable wire-like connection between juxtaposed ends ofthe rigid portions.
 16. The method of claim 13, wherein the second rigidportion defines a curve which is directed inward with respect to thering opening in the first configuration.
 17. The method of claim 13,wherein the restraint comprises a line of suture tied between the firstrigid portion and the second rigid portion.
 18. The method of claim 12,wherein the annuloplasty support frame defines a closed shape.
 19. Themethod of claim 12, wherein the annuloplasty support frame defines anopen, discontinuous shape.
 20. The method of claim 12, wherein thedilation balloon is configured with a pre-set inflated outer diameterwhich is 10-20% larger than the ring opening.
 21. The method of claim12, wherein the radially expansive force is between 1-6 atmospheres. 22.The method of claim 12, wherein in the first configuration the ringopening is “D”-shaped.
 23. The method of claim 1, wherein in the firstconfiguration the ring opening is “D”-shaped.